The double burden of malnutrition

Malnutrition is a global challenge and all countries need to address this critical issue for human resource development. Despite some progress, the world is not on track to meet globally agreed goals and targets for nutrition. Many countries are still facing problems of poverty, undernutrition and communicable diseases. At the same time, childhood overweight and obesity are increasing almost everywhere. The root of both problems is the same — a dearth of nutritious food. Millions are eating too little of what they need and millions are eating too much of what they don't need: poor diets are now the main risk factor for the global burden of disease. These two sides of the malnutrition issue are increasingly being referred to as a "double burden" for public health.

Interestingly, at present, a large proportion of low-income and middle-income countries (LMICs) face the double burden of malnutrition (DBM) that indicates the co-existence of undernutrition and overweight. About 2.28 billion children and adults worldwide are estimated to be overweight and more than 150 million children are stunted affecting countries, households and individuals. Obesity among adults is nearly as big a problem in the country as undernutrition. Even as under-nutrition continues to remain extraordinarily high in the poorer parts of the country, obesity has reached endemic levels in some of the richer parts of the country. Individuals who have a body mass index, or BMI, of 25 or more are considered overweight while those with a BMI less than 18.5 are considered underweight. Women seem to be affected more by both forms of malnutrition compared to men.

Now, the DBM is the major public health problems as both are linked with increased risk of morbidity and mortality among women of reproductive age and children, particularly in low-income and middle-income countries. Overweight and obesity lead to chronic illness, including increased risk of cardiovascular and metabolic diseases. Obesity is rapidly rising among children and young people around the world, driving early outbreaks of type 2 diabetes. Undernutrition, on the other hand, increases the risk of anaemia and adverse maternal and child outcomes (e.g. neonatal death, stillbirths and low birth weight). South Asia had the highest prevalence of global underweight with 24 per cent women being undernourished in 2014. Now the reverse trend is clearly evident because stunting and wasting, and thinness in many people are declining while overweight is increasing in most age groups. The negative impact of being underweight, overweight, or obese on the health and development of children and adolescents can also extend into adulthood, increasing the risk of chronic non-communicable diseases and disability. An enormous epidemic of lifestyle diseases, including obesity, are now among the biggest problems of modern medicine. Obesity places great physiological strain on the human body — and that strain takes a toll on many systems including on nutritional status. Morbid obesity is associated with deficiency of vitamins, A, E, C, D, selenium, folate and carotenoids.

According to the most recent surveys, a severe DBM is defined as wasting in more than 15 per cent and stunting in more than 30 per cent of children aged 0–4 years, thinness in women (body-mass index <18∙5 mg/kg²) in more than 20 per cent of females aged 15–49 years, and adult or child overweight, was found in 48 countries using the 20 per cent overweight prevalence threshold, 35 countries using the 30 per cent overweight prevalence threshold, and ten countries using the 40 per cent overweight prevalence threshold of all LMICs. In India, nearly one in two women are underweight in Purulia (West Bengal) and Malkangiri (Odisha) districts. These districts are among the poorest in the country. Four out of every 10 women are overweight in Kolkata and Hyderabad. Delhi and Mumbai also figure in the top quartile of districts with high levels of obesity but the proportion of obese people in these cities are lower compared to Kolkata and Hyderabad. Kerala and Tamil Nadu, Andhra Pradesh has among the highest levels of obesity in the country.

Increases in overweight are the result of economic change that has been crucial to the reductions in wasting, stunting, and thinness. Introduction of modern technology in home production (eg. rice cookers, refrigerators, air conditioner, floor cleaner, washing machine, stoves), and transportation systems have declined the physical activity of people that is also the major cause of overweight. Also, major shifts in the food system that have resulted in an increase in consumption of ultra-processed foods that make less nutritious food cheaper and more accessible. The high fat, salt and sugar junk snacks of affluent countries are now available in almost every village worldwide and are becoming part of the staple diet of some of the poorest families. The sale of breastmilk substitutes worldwide increased by 41 per cent from 2008–2013 has also aggravated the problem of childhood obesity. Very rapid changes in the diets and the food systems in energy imbalance cause weight gain. For example, drinking a 355 mL bottle of sugar-sweetened beverage requires to undertake a 1.5-mile walk or run for at least 15 min. During visit to many houses both in rural and urban areas, it was observed that sugary beverages and ultra-processed foods have become the food items for regular consumption even in many low-income families. Despite the consumption of these foods, they do not think of doing any physical activity to maintain the energy balance. India and China are two of the top five markets for sugary beverage manufacturers and sugary beverages in the next decade. Globally, only two in five children under six months are exclusively breastfed.

Upon policy liberalisation, the control of the entire food chain in many countries by agribusinesses, food retailers, food manufacturers, and foodservice private companies practically forced the people to increase their consumption of ultra-processed, packaged foods (often ready to use), rich in refined carbohydrates, fat, sugar, and salt. At present, about 100 giant firms dominate 77 per cent of global sales of processed food. These changes include disappearing fresh food markets, increasing numbers of supermarkets, and the control of the food chain by supermarkets and global food, catering and agriculture companies in many countries. Globalisation, urbanisation and the climate emergency are compounding unhealthy diets. Climate shocks, loss of biodiversity and damage to water, air and soil are worsening the nutritional prospects of millions of children and young people, especially among the poor. The speed of change is particularly important in understanding how this nutrition reality is shifting to weight gain. This new nutrition reality is particularly important to acknowledge because diet is an important driver of the DBM. The roles of income growth and the increase in the number of women working outside the home and the value of their time in work demand the food that is ready to eat or ready to heat and reduce the consumption of traditional crops (e.g. millet, green vegetables, maize, pulses, etc.). Another major bottleneck in maintaining energy balance on consuming these packaged foods is the engagement of children of

age 6-18 years in coaching centre particularly after school hour to secure a good score in the examination. Moreover, many children make themselves busy in playing games on mobile.

Obviously, population growth leads to overcrowding, poverty, undernutrition, environmental deterioration, poor quality of life and increase in disease burden. But at the same time, population growth can also be a major resource for economic growth. Now, appropriate policies and multi-sectoral strategies must be framed to prevent nutrition-related public health problems and improve the nutritional and health status of the population as optimal nutrition and health are prerequisites for human development. If India successfully faces the challenge of providing its younger, better-educated, skilled, well-nourished and healthy workforce with appropriate employment and adequate remuneration, the economic status of both people and the country can improve rapidly. With the increase of economic growth, if we can improve the access to dietary diversification and increase the consumption of pulses, vegetables, fruits and dairy products, the majority of the population will have a balanced diet to achieve nutrition security. The high-quality diet must contain lots of fruits and vegetables; whole grains, fibre, nuts, and seeds; modest amounts of animal source foods, minimal amounts of processed meats beverages high in energy and added sugar, saturated fat, trans fat and salt. High-quality diets reduce the risk of malnutrition by encouraging healthy growth, development, and the body's protection against diseases throughout life.

If the awareness regarding health and nutrition needs is created among 15–59 years age group, massive improvement in nutrition and health status can be made. Appropriate counselling will enable people to adopt lifestyles and diets that prevent the escalation of overnutrition and the non-communicable disease risk. Additionally, addressing all forms of malnutrition will require new ways of designing, targeting, and implementing programs and policies to accelerate progress in improving nutrition globally.

Dr Debapriya Mukherjee is a former Senior Scientist, Central Pollution Control Board. Views expressed are strictly personal